Effectiveness of a nurse-led pregnancy termination clinic

A new nurse-led service was developed for women requesting pregnancy termination. Compared with the previous service, the nurse-led clinic reduced waiting times and cost almost 40 per cent less.     

Telemedicine in rural care. Part 1: Developing and evaluating a nurse-led initiative

AIM: To develop and evaluate a nurse-led telemedicine service over a six-month period, linking the senior citizens of a rural village with the town-based general practice. METHOD: Patients, doctors and nurses were asked to complete a questionnaire following video-link sessions. Interviews were also carried out at home with patients, while interviews with nurses and doctors took place in the workplace. RESULTS: Of the 173 consultations with villagers aged over 65, 29 (17 per cent) were conducted by video-link. All those who used this service were sent questionnaires and 18 were returned (62 per cent). Seven of the patients who had received one video-link consultation were interviewed in their homes. All of the patients initially found the video consultation experience strange. Generally, patients found the nurses to have a pivotal role in explaining the service and interpreting their needs. All those interviewed said they would use the service again. The GPs spoke favourably of the service and said that it had saved them time. The nurses involved were positive about the service. Negative comments generally related to technology, for example picture and sound quality. CONCLUSION: All involved in the nurse-led telemedicine service viewed it favourably and patients said that they would use it again. Part two, to be published in next week's Nursing Standard, will discuss the findings of the evaluation in relation to the wider picture of nursing involvement in teleconsultation.     

Reducing re-admission for asthma: impact of a nurse-led service

High rates of re-admission of children with acute asthma led to the establishment of a nurse-led service in one hospital in England. Improved approaches to care, discharge planning and subsequent management were introduced based on the BTS/SIGN guideline for asthma management. These approaches included a reducing regime for salbutamol inhaler treatment, consistent assessment of need for regular preventer treatment and of 'step up' asthma control measures at home. Review of inhaler technique is particularly important to ensure that the appropriate drug delivery device is used depending on the age of the child. Telephone follow-up is used to re-enforce information provided prior to discharge. Subsequent follow up in the nurse-led clinic provides an opportunity to review the child's home management and effectiveness of any treatment changes. Audit data indicate a reduction in re-admission rates for children with asthma from 22 per cent to around six per cent.     

Ventilation perfusion lung scans in the management of suspected pulmonary embolism

The purpose of the study was twofold: (a) to relate the degree of clinical suspicion of pulmonary embolism (PE) to the findings of isotope ventilation-perfusion (V/Q) scans, and (b) to determine the extent to which the scan results influence patient management. A questionnaire was completed by the requesting clinician before V/Q scanning in 60 consecutive in-patients in whom PE had, with varying degrees of probability, been considered possible. Retrospectively, the case notes were reviewed to determine whether or not the patients were anticoagulated when discharged. Prior to scanning, PE was considered probable or almost certain in 35 (58 per cent) patients and unlikely or very unlikely in 25 (42 per cent) patients. Thirty-seven (62 per cent) scans were confidently reported positive or negative for PE; in the remaining 23 (38 per cent) cases, the scan report was necessarily inconclusive. The clinical assessment was supported by the scan result in 23/25 (92 per cent) patients in whom PE was felt unlikely or very unlikely, but in only 14/35 (40 per cent) in whom this diagnosis was felt probable or almost certain. Twenty (33 per cent) patients were already anticoagulated when scanned; this treatment was initiated in nine (15 per cent) and discontinued in eight (13 per cent) in the light of the scan result. Isotope V/Q scans are not always useful in confidently confirming or excluding the presence of PE. Nevertheless, the scan reports, even when necessarily guarded and somewhat at variance with the clinical assessment of the probability of PE, strongly influence clinicians in their decisions as to whether to anticoagulate their patients.     

Comparing doctor- and nurse-led care in a sexual health clinic: patient satisfaction questionnaire

BACKGROUND: A new model of comprehensive care nurse-led clinics has enabled experienced genitourinary medicine nurses to co-ordinate the first-line, comprehensive care of female patients presenting with sexually transmitted infections and other sexual health conditions and issues. AIM: This paper describes the development of a patient satisfaction questionnaire to compare the satisfaction of women attending nurse-led or doctor-led clinics at a central London genitourinary medicine clinic. METHODS: A previously validated questionnaire was adapted using the findings of qualitative interviews exploring patient expectations of the service. The draft questionnaire was tested for internal consistency, sub-scale homogeneity, construct validity and stability. The final version consisted of a 34 item, five-point Likert scale, which was found to be both reliable (Cronbach's alpha 0.91) and stable (test-retest 0.95). There was some evidence of construct validity. The questionnaire was then distributed to a convenience sample of 132 women attending a nurse-led clinic and 150 seen at a doctor-led clinic. RESULTS: There was a 90% response rate. The median total satisfaction scores, out of a total of five, were 4.47 and 4.30 for the nurse-led and doctor-led groups, respectively (P = 0.05). Significantly higher scores on the sub-scales measuring quality and competence of technical care (P < 0.001), provision of information (P = 0.01) and overall satisfaction (P = 0.01) were seen for the nurse-led group. No significant differences were found in the sub-scales measuring service attributes and specific attributes of interpersonal relationships. CONCLUSION: The rigorous development, piloting and testing phases of this satisfaction questionnaire led to reliable and valid results. This study demonstrated that nurse-led clinics within this service are an acceptable alternative to the existing doctor-led clinics.     

A patient satisfaction survey of a nurse-led colorectal clinic

A new service was set up to achieve government targets to see patients with signs or symptoms of a possible colorectal cancer within two weeks of referral from their GP. The new clinics were nurse-led. A patient satisfaction survey was used to assess patients' opinions about the clinic. The results showed patients had a positive view of the clinic.     

The safety and effectiveness of a nurse-led anticoagulant service

AIM: The aim of this study was to compare the safety and effectiveness of anticoagulant nurses and a consultant haematologist in managing anticoagulant patients in a hospital outpatient setting. BACKGROUND: Nurses are increasingly developing roles traditionally undertaken by medical staff. As a result nurse-led practice has expanded in many areas including anticoagulant services. Previous studies have attempted to demonstrate the effectiveness of using other professionals to manage anticoagulant clinics over short periods of time. This research evaluates the safety and effectiveness of a consultant-led and a nurse-led service over two sequential 18-month periods. RESEARCH METHODS: A nonexperimental design was adopted. Data were collected retrospectively, from a random sample of 197 patients, who had been managed by both the consultant-led and nurse-led service. Two main outcome measures were selected: anticoagulant control between professional groups and interval between outpatient clinic appointments. RESULTS: No statistically significant difference in anticoagulant control was found between professional groups (P=0.137). There was evidence that patients attended anticoagulant clinics on significantly fewer occasions with nurse-led management (P < 0.0005). CONCLUSION: At the department within which this research was conducted, anticoagulant nurses were found to be at least as safe and effective as the consultant haematologist in managing outpatient anticoagulant patients over the study period. These findings are of importance in both shaping the future provision of anticoagulant care and also contributing to the wider area in evaluating the impact of nurse-led practice within health care.     

The role of new health practitioners in a prepaid group practice: provider differences in process and outcomes of medical care.

Practice patterns and patient-reported outcomes of care are compared in detail for ten physicians and 12 new health practitioners delivering ambulatory care in two departments of a prepaid group practice, the Columbia Medical Plan (CMP). All providers completed questionnaires for a 50 per cent random sample of patients seen during a two-week period. Patients completed questionnaires prior to receiving care and were interviewed one week and one month after their clinic visits. New health practitioners deliver approximately 75 per cent of well-person care, 56 per cent of problem-oriented care in adult medicine, and 29 per cent of problem care in pediatrics. They have become increasingly involved over time in the treatment of acute conditions and injuries while physicians have retained their predominant role in treating patients with chronic conditions. Thirty-two per cent of visits with new healh providers involved a physician in one or more of the following: decision-making, direct supervision, consultation, or seeing the patient as a second provider of care. Degree of autonomy varied by type of task performed, category of problem treated, and specialty. The following outcomes of care were examined by type of provider: patient-reported change in problem status,including frequency and intensity of pain or discomfort, level of anxiety, and degree of activity limitation; the degree to which physician-specified criteria for the most commonly occurring conditions were met with respect to change in problem status; and patient satisfaction with a number of dimensions of the clinic visit. The analysis suggests that the new health practitioners at the CMP are providing care, within their areas of responsibility, of comparable quality to that delivered by physicians.     

The impact of a nurse-led clinic on self-care ability, disease-specific knowledge, and home dialysis modality

A nurse-led clinic focusing on education and self-care for patients with advanced renal failure was introduced in a renal outpatient clinic in Sweden. The purpose was to enhance patients' disease-related knowledge, involvement, and self-care ability. This article reports the results of a study comparing patient outcomes with the nurse-led clinic to the previous model of care. The hypothesis was that the nurse-led clinic would increase medical control and self-care outcomes. The participants in the nurse-led clinic chose and started dialysis in a self-care alternative and also had a functioning, permanent dialysis access to a greater extent than the patients in the comparison group. Those choosing home-hemodialysis rated their self-care ability higher. The participants rated self-care and effects of treatment options on family and everyday life as the most important disease-related areas of knowledge.     

A survey of the practice of stroke doctors in developing transient ischaemic attack services in the UK

RATIONALE, AIMS AND OBJECTIVES: (1) To describe current practice in the establishment and running of transient ischaemic attack (TIA) clinics in the UK; (2) to identify whether TIA targets are met; (3) to inform future TIA service development. METHODS: A survey distributed to the members of the British Association of Stroke Physicians (BASP). RESULTS: Forty-one per cent of full BASP members responded to the survey. TIA clinics were being run by 77% of respondents. Of the remainder 75% had plans to do so. Dedicated consultant time for stroke predominated among those involved in clinics (87% vs. 54%). The median time for clinics operation was 36 months. The median time from TIA to appointment was 2 weeks, exceeding national targets. Sixty-four per cent of clinics were run weekly and 31% more than once a week. Forty-six per cent stated they ran a one-stop clinic service yet only 10% said there were no later follow-up visits. A patient returning for completion of investigations was the most common reason for this (60%). Waits for investigations were reported - 53% indicated a wait for carotid Doppler scanning and 41% indicated this wait was in excess of 1 week. CONCLUSION: Key areas of concern arising from this survey were that time from TIA to clinic appointment remained outside the national target and there were delays for key investigations. Current service models are inadequate to meet current TIA targets and exploration of alternative service models is required.     

A comparison of gray scale ultrasound and radionuclide imaging for the detection of focal hepatic lesions: open shutter technique.

A conventional B scan ultrasound unit was modified by the addition of a specially built logarithmic amplifier and a high resolution nonstorage oscilloscope, as suggested by Taylor and Carpenter. One hundred five consecutive patients submitted for radionuclide imaging of the liver were examined with ultrasound using a standardized scanning system. The ultrasound technique produced scans that were technically poor or inadequate in 37 per cent of the patients studied. In the studies in which there has been confirmation, the ultrasound diagnosis was accurate in 73 per cent and the radionuclide diagnosis was correct in 83 per cent. The combined accuracy of the two studies was 93 per cent. In 11 patients, ultrasound more clearly defined the lesions that were demonstrated by both techniques or demonstrated the nature of suspicious or equivocal areas on the radionuclide images. In 48 patients, the radionuclide scan imaged the liver more completely or demonstrated lesions more clearly than did the ultrasound examination. This specific approach to ultrasound gray scale imaging appears to be a valuable supplemental tool to radionuclide imaging, but at its present stage of development cannot replace it as a routine screening technique for hepatic disease.     

Impact of community based nurse-led clinics on patient outcomes,patient satisfaction,patient access and cost effectiveness: A systematic review

BackgroundThe role and scope of nursing practice has evolved in response to the dynamic needs of individuals, communities, and healthcare services. Health services are now focused on maintaining people in their communities, and keeping them out of hospital where possible. Community based nurse-led clinics are ideally placed to work towards this goal. The initial impetus for these services was to increase patient access to care, to provide a cost-effective and high quality streamlined service.ObjectivesThis systematic review aimed to identify the impact of nurse-led clinics in relation to patient outcomes, patient satisfaction, impact on patient access to services, and cost effectiveness.MethodsA review of community based nurse-led clinic research in Medline, CINAHL and Embase was undertaken using MeSH terms: Nurse-managed centres, Practice, Patterns, Nurse, Ambulatory Care, keywords: nurse-led clinic, nurse led clinic, community and phrases primary health care and primary care. Papers were appraised using the Joanna Briggs Appraisal criteria.ResultsThe final review comprised 15 studies with 3965 participants. Most studies explored patient satisfaction which was largely positive towards nurse-led clinics. Patient outcomes reported were typically from self-report, although some papers addressed objective clinical measures; again positive. Access was reported as being increased. Cost-effectiveness was the least reported impact measure with mixed results.ConclusionsNurse-led clinics have largely shown positive impact on patient outcomes, patient satisfaction, access to care and mixed results on cost-effectiveness. Future research evaluating NLCs needs to adopt a standardised structure to provide rigorous evaluations that can rationalise further efforts to set up community based nurse-led clinical services.     

Development of a nurse-led ileo-anal pouch clinic

The ileo-anal pouch procedure is now seen as the operation of choice for individuals suffering with ulcerative colitis or familial adenomatous polyposis (Fazio, 1999); however, patient follow-up after this surgery remains variable. This article highlights the effectiveness of running a nurse-led follow-up service. A patient satisfaction survey has shown that having a familiar face at each follow-up visit is hugely beneficial, providing continuity and reassurance for patients and their relatives. This nurse-led clinic provides adequate time for patients to discuss a variety of issues including management of sore perianal skin and pouch dysfunction. The growth and development in clinical skills, knowledge and nursing autonomy has seen the emergence of many nurse-led clinics, where nurses are utilizing their advanced skills. Within the nurse-led ileo-anal pouch clinic in Oxford, physical and/or internal examination, and investigations, such as rigid or flexible pouchoscopy, are performed. Such procedures were positively evaluated by patients.     

Evaluation of a service development to implement the top three process indicators for quality stroke care

RATIONALE, AIM AND OBJECTIVE: Stroke mortality remains unacceptably high with up to 30% of patients dying within 1 month. Early swallow screen and computerized tomography (CT) brain scan, facilitate delivery of aspirin, which together are recognized as the top three process indicators for quality stroke care. Evidence indicates that treatment with aspirin (300 mg) saves lives and should commence within 48 h of stroke onset. However, many hospitals find it difficult to meet this timescale. We aimed to evaluate whether reorganization of services could improve aspirin delivery following acute ischaemic stroke. METHOD: A retrospective audit was carried out to determine the time to swallow screen, CT scan and aspirin administration. A service review was conducted and the findings disseminated. A decision was made to reorganize services by enhancing the role of senior nursing staff to: (1) admit patients, (2) request CT brain scans, (3) screen for swallowing abnormality, and (4) prescribe the first dose of aspirin. A second audit was conducted to evaluate the impact of the new service. RESULTS: Before reorganization, 30% had swallowing screened and 38% had CT scans within 24 h. Thirty-one per cent received their first dose of aspirin within 48 h. After reorganization, 68% had their swallowing screened and 80% had a CT scan within 24 h. Ninety per cent of patients received their first dose of aspirin within 48 h. CONCLUSIONS: Modernizing service delivery by changing traditional roles can offer quality solutions ensuring that aspirin delivery is expedited by early swallow screen and CT scan. These initiatives could be used more widely to improve patient care and implement the top three process indicators for stroke.     

Nurse-Led Follow-Up at Home vs. Conventional Medical Outpatient Clinic Follow-Up in Patients With Incurable Upper Gastrointestinal Cancer: A Randomized Study

ContextUpper gastrointestinal cancer is associated with a poor prognosis. The multidimensional problems of incurable patients require close monitoring and frequent support, which cannot sufficiently be provided during conventional one to two month follow-up visits to the outpatient clinic.ObjectivesTo compare nurse-led follow-up at home with conventional medical follow-up in the outpatient clinic for patients with incurable primary or recurrent esophageal, pancreatic, or hepatobiliary cancer.MethodsPatients were randomized to nurse-led follow-up at home or conventional medical follow-up in the outpatient clinic. Outcome parameters were quality of life (QoL), patient satisfaction, and health care consumption, measured by different questionnaires at one and a half and four months after randomization. As well, cost analyses were done for both follow-up strategies in the first four months.ResultsIn total, 138 patients were randomized, of which 66 (48%) were evaluable. At baseline, both groups were similar with respect to clinical and sociodemographic characteristics and health-related QoL. Patients in the nurse-led follow-up group were significantly more satisfied with the visits, whereas QoL and health care consumption within the first four months were comparable between the two groups. Nurse-led follow-up was less expensive than conventional medical follow-up. However, the total costs for the first four months of follow-up in this study were higher in the nurse-led follow-up group because of a higher frequency of visits.ConclusionThe results suggest that conventional medical follow-up is interchangeable with nurse-led follow-up. A cost utility study is necessary to determine the preferred frequency and duration of the home visits.     

Laboratory investigation in the diagnosis of pulmonary thromboembolism.

Laboratory findings were compared with lung scans in a prospective study of 260 patients undergoing ventilation-perfusion (V/Q) lung scanning for suspected pulmonary thromboembolism. The best discrimination between different lung scan results was obtained from the level of plasma cross-linked fibrin degradation products, every patient with a scan indicating a high probability of thromboembolism having detectable levels. An acute phase response was demonstrated in patients with pulmonary thromboembolism by a raised neutrophil count and elevated levels of plasma fibrinogen and serum C-reactive protein. A normal level of serum C-reactive protein and/or plasma cross-linked fibrin degradation productions in blood taken within 4 days of onset of symptoms virtually excluded the diagnosis of pulmonary thromboembolism. Detection of free plasma DNA was not helpful in discriminating between groups with different lung scan results. Discriminant analysis was used to assess the variables examined and to derive diagnostic models. An accuracy of 78 per cent was obtained with one model for classifying test patients according to the three lung scan classes of low, intermediate and high probability. A second model, for distinguishing patients with a low and a high probability of pulmonary thromboembolism on the basis of lung scans, and a third for predicting those with a low probability on lung scan, were accurate in 94.6 per cent and 83.5 per cent of patients respectively. Discriminant models could be used in the diagnosis of pulmonary thromboembolism, especially when diagnostic imaging is not available.     

The impact of 2-deoxy-2[18F] fluoro-D-glucose whole body positron emission tomography for managing patients with melanoma: the referring physician's perspective.

PURPOSE: Whole body positron emission tomography (PET) imaging with 2-deoxy-2[18F]fluoro-D-glucose (FDG) has been used successfully to diagnose and stage melanoma. The impact of FDG-PET, however, on patient stage and management from the referring physicians' perspective is unknown. PROCEDURES: A questionnaire was sent to referring physicians to investigate whether and how PET altered clinical decision in treatment of melanoma patients. Surveys were sent to referring physicians of every melanoma patient who had a PET scan performed at UCLA or the Northern California PET Imaging Center (NCPIC). Data were used to evaluate the impact of FDG-PET on clinical management of melanoma patients based on pre-PET and post-PET staging. Management changes were classified as inter-modality if therapy changed from one modality to another or intra-modality if changes were made within a treatment modality. RESULTS: Fifty-one questionnaires (response rate of 35%) have been received to date. Referring physicians indicated that whole body FDG-PET changed the clinical stage in 15 out of 51 (29%) patients: 10 (20%) were up-staged and five (10%) were down-staged. The PET findings resulted in inter-modality management changes in 15 out of 51 patients (29%). Intra-modality management change occurred in nine patients (18%). CONCLUSION: From the referring physicians' perspective, FDG-PET has a major impact and results in management changes in 53% of patients with melanoma.     

Unrestricted access to mental health services

BACKGROUND: This study examines referrals to a nurse-led, community-based, acute psychiatric assessment and treatment centre in the north west of England which operates an open referral system. Data were collated over 12 months and the total number of assessments was 1,544. It focused on the appropriateness of emergency assessments, which accounted for 29 per cent (n = 446) of the total. In considering 'appropriateness' the authors examined each assessment by source, risk, diagnosis and outcome. CONCLUSION: The results show that professionals and non-health professionals, such as the patient themselves, carers or a voluntary group, are equally likely to make inappropriate referrals, but, overall, open access was used efficiently by both groups. The results also indicate that open access to the service enabled early intervention for high-risk client groups. Implications for professionals and services are discussed.     

Rapid access for patients with head and neck lumps

BACKGROUND: In the White Paper The New NHS: Modern, Dependable (DoH 1997), the government states that anyone with suspected cancer will be able to be seen by a specialist within two weeks of referral by a GP. Staff at Southport General Infirmary set up a rapid access clinic for patients referred with a neck lump to meet these targets. A protocol was devised to deal with these new patients and the clinic was audited during the first six months to ensure that the two-week target was being met. CONCLUSION: The results of the audit showed that the rapid-access clinic was able to provide a fast, quality service for this small number (n = 58) of patients. The majority (n = 49) (84 per cent) of patients were seen within the target time. The remaining patients were not seen within the two-week target because of delays in receiving GP referrals and patients' difficulties in meeting the allocated appointment.     

A nurse-led service for acute exacerbation of COPD

One in four of all hospital admissions are due to respiratory disease and half of these are due to chronic obstructive pulmonary disease (COPD). In Wigan this has been tackled using 'The Wigan Model', which incorporates acute COPD assessment and early discharge. The service, established in 1999, is specialist nurse-led with referrals from GPs, the A&E department and the medical assessment unit. Specialist nurses instigate investigations and perform a clinical assessment; suitable patients are discharged with treatment dispensed and administered by the nurse and are visited at home for two weeks. A recent survey of patient satisfaction questionnaires has shown that most patients are happy with the service and find it beneficial to have their acute episode managed at home.